Presented By: Rusli 110980042

The purpose of this study was to evaluate the effectiveness and complication rate of guided growth for the treatment of patients with a moderate leg-length discrepancy. The authors retrospectively reviewed all patients treated with guided growth for a moderate leg-length discrepancy at their institution between October 2004 and December 2010

Epiphysiodesis was first reported by Phemister1 in 1933 to correct predicted leg-length discrepancies in children. The echnique was modified by White and Stubbins in 1944. Percutaneous epiphysiodesis using transphyseal screws was reported by Metaizeau et al in 1998. Guided growth has been used for epiphysiodesis since 2004, with the first case performed by the senior author (P.M.S.).

Databases of all pediatric orthopedic surgeons at Primary Childrens Medical Center, Salt Lake City, Utah, were queried for cases involving epiphysiodesis. One hundred five patients were initially identified between October 2004 and December 2010.

Patients who underwent guided growth of the femur, tibia, or both for a leg-length discrepancy of less than 5 cm; Had adequate radiographs Had no knee or ankle contractures Had undergone no concomitant lengthening or shorten ing procedures Had undergone only 1 epiphysiodesis procedure (although they may have previously undergone hemiepiphysiodesis) Had no significant angular deformity prior to treatment that recurred during treatment

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Measured from the top of the femoral head to the center of the ankle. Drew a horizontal line from the top of the femoral head of the long side and measured vertically down from this line to the top of the femoral head on the short side. Drew a horizontal line from the top of the pelvis on the longer side and measured vertically down from this line to the top of the pelvis on the shorter side.

Univariate summaries of patient: Demographics, Diagnosis, Location of epiphysiodesis, Associated procedure, pre- and postoperative differences in leg-length height, Iliac crest height, and femoral head height

Patients underwent a standard approach to the either the medial or lateral side of the distal femur, proximal tibia, or both. A Keith needle was used to identify the central part of the growth plate with the help of fluoroscopy. The 2-hole Orthofix 8-plate (Orthofix, Inc, Lewisville, Texas)was then placed over the Keith needle through the 8-plates central hole. Guidewires were placed through the screw holes in the 8-plate.

The guidewires were removed, and the screws were further tightened. A final fluoroscopic examination was performed to ensure that placement did not involve the physis and that the plate was centered anterior to posterior on the lateral view. The wound was then closed in layers.

Average starting leg-length discrepancies as measured on standing long-leg radiographs for the iliac crest height, femoral head height, and leg-length height were 22, 19, and 17 mm. Average discrepancies at screw removal or maturity were 13, 11, and 10 mm. Average change in leg-length discrepancy measuring the leg-length height when both the femur and tibia were tethered was 10.5 mm. Average change in leg-length discrepancy was 9.8 mm when the femur was tethered and 20.4 mm when the tibia was tethered.

Thirty-three of 34 patients had a mechanical axis in medial or lateral zone 1. One patient had a mechanical axis zone change greater than 1 zone that did not require treatment. One patient developed clinical genu varum requiring treatment with hemiepiphysiodesis (in medial zone). One patient developed cellulitis after plate removal and required antibiotics. One patient developed clinical genu varum that required treatment. Fifteen of 34 patients had less than 5 mm of change in leg-length discrepancy when measuring the leglength height.

Eleven of 33 patients had less than 5 mm of change when measuring the iliac crest height (1 patient could not be measured from the top of the pelvis because the radiograph did not include it). Ten of 34 patients had less than 5 mm of change when measuring the femoral head height. Seven of 10 patients who underwent tibial epiphysiodesis had a leg-length discrepancy change of less than 5 mm.

 Standing long-leg anteroposterior radiographs of an 11-year-old girl with clubfoot showing an initial leg-length discrepancy of 2.2 cm (A), the leglength discrepancy improving with guided growth, with the femoral head height closer to level, (B), and a 0.4-cm leg-length discrepancy after plate removal when the patient reached skeletal maturity (C).

Numerous techniques are available for leglength equalization in growing children. Percutaneous epiphysiodesis has been efficacious in numerous reports. Failure of epiphysiodesis with a resultant angular deformity has been reported by numerous authors. Metaizeau et al6 popularized percutaneous epiphysiodesis with transphyseal screws

The current authors recommend adding 1 year to the timing of a standard physeal closing epiphysiodesis. Metaizeau et al6 reported growth retardation in 47% of patients over the first 6 months vs 62% in between 6 and 18 months.

Guided growth for the treatment of a moderate leg-length discrepancy is a safe and efficacious technique with minimal complications. The advantages of this technique are that it is reversible, the plate and screws are easy to remove, and little chance exists that the screw will be pushed into the bone cortex. The disadvantages are that it is expensive compared with a single screw and a slightly larger incision is needed.

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